Malaysian Family Physician 2010; Volume 5, Number 1 ISSN: 1985-207X (print), 1985-2274 (electronic) ©Academy of Family Physicians of Malaysia Online version: http://www.e-mfp.org/ CME Article PHOTOAGEING SKIN OF THE ELDERLY SB Khoo FRACGP, Penang Medical College Address for correspondence: Dr Khoo Siew Beng, Senior Lecturer & Family Physician, Penang Medical College, No 4, Sepoy Lines Road, 10450 Penang, Malaysia. Tel: 604-2263 459, Email: [email protected] Khoo SB. Photoageing skin of the elderly. Malaysian Family Physician. 2010;5(1):9-12 CASE HISTORY Figure 2: Dorsal view of both forearms Mr A is an 80 year old man who presents with several warty skin lesions on his forearms for past 6 months. There was no complaint of pain or itch except occasional irritation when he accidentally rubbed against them. He noticed that these skin lesions had gradually increased in size and number. Mr A is generally well and healthy with a functional age of 65 years. He does not have any medical problem except for mild hypertension controlled well with atenolol 100mg daily. He used to work as a Chinese opera singer in his younger days and is now retired. Currently he spends his time providing service in church and help to make handicrafts to raise funds for the church and charitable old folk’s homes. Figure 3: Closer dorsal view of right forearm Physical examination (Figures 1-3) reveals extensive solar damaged skin on sun exposed areas of both forearms. There are scattered areas of hyperpigmentation (solar lentigo), isolated patches of hypopigmentation (solar hypomelanosis), skin atrophy, presence of wrinkles, telangiectasia and superficial areas of ecchymosis. Several small irregular, crusty, warty type of lesions were seen in this background of solar damaged skin. Mr A was referred to a dermatologist who performed a skin biopsy. Results came back as positive for squamous cell carcinoma (SCC). He was referred to a radiotherapist and received a full course of 30 fractions of curative doses of Questions radiation. His warty skin lesions completely subsided but 2 1. What is the clinical term for these warty lesions? years later similar lesions cropped up again at different sites 2. Describe the photoageing effects on skins of elderly on the forearms. people. 3. What are the differential diagnoses to consider? Figure 1: Side view of both forearms 4. List the various management options for such skin lesions. Answers 1. Actinic or solar keratosis. 2. Photoageing effects on skin of elderly. 3. Differential diagnoses included basal cell carcinoma, squamous cell carcinoma, seborrhoeic keratosis, Bowen’s disease, discoid lupus erythematosus, viral warts and simple lentigo (lentigo simplex). 4. No specific investigations are required unless there is suspicion that the lesion may be malignant when biopsy is needed. 9 Malaysian Family Physician 2010; Volume 5, Number 1 ISSN: 1985-207X (print), 1985-2274 (electronic) ©Academy of Family Physicians of Malaysia Online version: http://www.e-mfp.org/ INTRODUCTION It is estimated that 60% of predisposed persons older than 40 years have at least one AK.3 Prevalence of the disease among Ageing is accelerated in those areas exposed to sunlight due white people ranges from less than 10% in persons 20 to 29 to damaging effects of ultraviolet B (UVB with short years of age to 75% in those 80 to 89 years of age.4 wavelengths) to the epidermis, ultraviolet A (UVA with longer wavelengths) to the dermis and infrared radiation to the deeper The main concern is that solar keratoses can give rise to SCC dermis and subcutaneous tissue. This process is termed as of the skin. The risk of SCC occurring in a patient with more photoageing.1 than 10 solar keratoses is about 10% to 15%.2,3 Although most AK do not progress to cancer, and as many as 26% regress Actinic keratoses (AK), also known as solar keratoses, are spontaneously,5 up to 60% of cutaneous SCC arise from AK.6 abnormal skin cell development due to exposure to ultraviolet After progression to SCC has occurred, the risk of metastasis radiation. They appear as multiple flat or thickened, scaly or is estimated to be 0.5% to 3.3%.7 warty, skin coloured or reddened lesions and may sometimes develop into a cutaneous horn. More than 80% of AK occurs on areas of the skin with the most sun exposure such as the PHOTOAGEING EFFECTS ON SKIN OF ELDERLY backs of the hands and forearms, on the neck and face, especially the nose, cheeks, upper lips, temples and Ultraviolet exposure causes thickening and thinning of skin foreheads.2 UV radiation is thought to be the major aetiological textures, changes in skin pigments, loss of elasticity and factor, with age, immunosuppression and human thinning of walls of blood vessels. Table 1 summarizes the papillomavirus being important contributing factors. clinical skin effects of UV radiation. Table 1: Photoageing effects of sun exposure1,2 Manifestations Description of skin lesions Sunburn Redness and tenderness of the skin after 12 to 24 hours of sun exposure. Idiopathic guttate hypomelanosis Hypopigmented macules. Solar / senile lentigines Dark hyperpigmented macules described as sun induced freckles. Seborrhoeic keratoses Warty lesions that appear like flattened raisins pressed onto the skin. Actinic or solar keratoses Small rough, scaly or warty areas of skin. Actinic cheilitis (“farmer’s lip” or “sailor’s lip”) Persistent dryness and cracking of the lips. Nevus (mole) Benign hyperpigmented skin lesion, made up of pigment producing cells (melanocytes). Cutis rhomboidalis nuchae “Leather-like” skin folds and creases on the neck. Poikiloderma of Civatte Specific pattern of colour changes, typically occurs on the neck in a V-shaped distribution on the upper chest that includes hypopigmentation, redness and a thin “chicken-skin” appearance. Telangiectases Linear streaks of dilated small blood vessel. Cherry angiomas Conglomerates of dilated blood vessels appearing as bright red raised “cherries”. Bruises, ecchymoses Weakened blood vessels easily breaks with resultant bleeding into the skin. Fine lines and wrinkles Loss of elasticity and thinning of epidermis makes the skin feels dry, easily blisters, tears and grazes. Elastosis or heliosis Yellow thickened bumps due to tangled masses of damaged elastin protein in the dermis. Solar comedones Blackheads and whiteheads due to plugging of hair follicles with dead skin and broken down cellular proteins. Colloid milia Shiny brown gel-filled bump. Similar cause as comedones. Melanoma Most deadly skin cancer that metastasizes more readily than the other skin cancers. Basal cell carcinoma Most common skin cancer that tends to spread locally but not metastasize. Squamous cell carcinoma Second most common skin cancer, and it can metastasize although not as commonly as melanoma. 10 Malaysian Family Physician 2010; Volume 5, Number 1 ISSN: 1985-207X (print), 1985-2274 (electronic) ©Academy of Family Physicians of Malaysia Online version: http://www.e-mfp.org/ DIFFERENTIAL DIAGNOSES8 MANAGEMENT OPTIONS The following differential diagnoses should be considered: No specific investigations are required unless there is suspicion that the lesion may be malignant when biopsy is needed. These o Basal cell carcinoma and squamous cell carcinoma signs includes:8 (SCC). These are indurated nodular lesions reflecting more rapid growth and tend to be eroded or ulcerated on the o Lesions with pronounced hyperkeratosis, increased surface. erythema, or induration. o Seborrhoeic keratosis. These skin lesions appear as o Lesions that recur. greasy, brown crusts with a sharply demarcated borders o Lesions which are unresponsive to treatment. and a non-erythematous base. They give the impression o Large confluent lesions. of flattened raisins pressed on to the skin and may occur in areas that are not exposed to sun. They are not o Lesions in transplant recipients. premalignant. o Lesions in patients with a history of SCC. o Bowen’s disease. This “in-situ squamous cell carcinoma” presents as multiple red slowly-growing crusted patches, With a substantial proportion of solar keratoses remitting most often on the lower legs. They tend to appear as a spontaneously, plus the low rate of malignant transformation large plaque with a sharp well defined outline. and the low potential for metastasis to occur from SCC arising o Discoid lupus erythematosus. These skin lesions show in a solar keratosis, treatment is not universally required on 9 abnormal pigmentation, dilated follicles and atrophy. the basis of preventing progression into SCC. However, others feel that prevention of SCC is the main reason for therapy.10 o Viral warts. Simple benign viral warts can appear anywhere Decision to treat is made on related clinical factors such as on the body, not necessarily on sun exposed areas. history of persistence, age of patient, discomfort, extent of Surrounding skins are normal in appearance. coexisting photodamage, tolerance for morbidity of therapy o Simple lentigo (lentigo simplex). These are not related and history of skin cancer.11 to sun exposure. Treatment options are listed in Table 2. Table 2: Treatment options2,8,12 Treatments Effectiveness No treatment or topical emollient Reasonable for mild actinic keratoses. Topical Treatments: 1. Sun block Applied twice daily for 7 months may protect against development of AKs. 2. 5-fluorouracil cream Twice a day for 6 weeks is effective up to 12 months in clearance of the majority of AKs. 3. Diclofenac gel Has moderate efficacy with low morbidity in mild AKs. 4. Imiquimod 5% cream An immune response modifier in a cream base. It is applied to areas affected by AK two or three times weekly for four to sixteen weeks. It causes an inflammatory reaction, which is maximal at about three weeks and then gradually settles down with continued use. The results are variable, but generally excellent. Other treatments: 1. Cryosurgery Effective for up to 75% of lesions in trials.